Vanessa Kennedy

Can you ask? We just did! Assessing sexual function and concerns in patients presenting for initial gynecologic oncology consultation

OBJECTIVES To describe patterns of response to, and assess sexual function and activity elicited by, a self-administered assessment incorporated into a new patient intake form for gynecologic oncology consultation. METHODS A cross-sectional study of patients presenting to a single urban academic medical center between January 2010 and September 2012. New patients completed a self-administered intake form, including six brief sexual activity and function items. These items, along with abstracted medical record data, were descriptively analyzed. Logistic regression was used to assess the association between sexual activity and function and disease status, adjusting for age. RESULTS Median age was 50 years (range 18-91, N=499); more than half had a final diagnosis of cancer. Most patients completed all sex-related items on the intake form; 98% answered at least one. Among patients who were sexually active in the prior 12 months (57% with cancer, 64% with benign disease), 52% indicated on the intake form having, during that period, a sexual problem lasting several months or more. Of these, 15% had physician documentation of the sexual problem. Eighteen women were referred for care. Providers reported no patient complaints about the inclusion of sexual items on the intake form. CONCLUSIONS Nearly all new patients presenting for gynecologic oncology consultation answered self-administered items to assess sexual activity and function. Further study is needed to determine the role of pre-treatment identification of sexual function concerns in improving sexual outcomes associated with cancer diagnosis and treatment.

Physical examination of the female cancer patient with sexual concerns: What oncologists and patients should expect from consultation with a specialist

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Sexual Health in Women Affected by Cancer: Focus on Sexual Pain

As cancer therapies improve, the number of women surviving or living long lives with cancer continues to increase. Treatment modalities, including surgery, chemotherapy, radiotherapy, and hormonal therapy, affect sexual function and may cause sexual pain through a variety of mechanisms, depending on treatment type. Adverse sexual effects resulting from ovarian damage, anatomic alterations, and neurologic, myofascial, or pelvic organ injury may affect more than half of women affected by cancer. Despite the fact that no specialty is better qualified to render care for this consequence of cancer treatments, many obstetrician-gynecologists (ob-gyns) feel uncomfortable or ill-equipped to address sexual pain in women affected by cancer. Asking about sexual pain and dyspareunia and performing a thorough physical examination are essential steps to guide management, which must be tailored to individual patient goals. Understanding the cancer treatment-related pathophysiology of sexual pain aids in providing this care. Effective mechanism-based treatments for sexual pain and dyspareunia are available, and by using them, knowledgeable ob-gyns can enhance the quality of life of potentially millions of women affected by cancer.

Preserving sexual function in women and girls with cancer: survivorship is about more than just surviving

exual health is difficult to define, but we know it when we whether she is having difficulties with her sexual function S see it. As defined by a technical report published by the World Health Organization in 2006, “Sexual health is a state of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled.” Long considered “just” a quality-of-life issue, research points to much broader implications of impaired sexual health than previously understood. Whereas the value individuals place on sex does vary, sexual health is central for many women in maintaining intimate partnerships and a sense of general well-being, and for some, the socioeconomic consequences of relationship strain can be immense. This concept of sexual health is further complicated in women with a diagnosis of cancer. Female sexuality remains an element of well-being more likely to be discussed among girlfriends than with one’s physician. Although both physicians and patients indicate that sexual health is important, providers list many barriers to addressing these issues in women with cancer. Barriers include a fear of making the patient and/or provider uncomfortable, lack of adequate time, training or resources to address such concerns, lack of evidence-based solutions to problems that may arise, and/or a feeling that is the responsibility of the patient or another provider to raise these issues. Despite these barriers to discussing sexual health with female cancer patients, research shows that sex is important to these patients, across age groups and cancer types, and that sexual problems are common. Perhaps most importantly, patients are interested in discussing sexual health issues with a provider, given the opportunity. Simply asking the patient

Unusual Clinical Presentation of Disseminated Gestational Trophoblastic Neoplasia [19P]

INTRODUCTION: Gestational trophoblastic neoplasia (GTN) is comprised of malignant tumors characterized by an abnormal proliferation of trophoblastic tissue. Subtypes include invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Clinical presentation of GTN varies based on location and extent of disease. Here we report the case of a patient who presented with atypical symptoms of GTN and was ultimately found to have massive disseminated tumor burden, greater than any prior reported case. METHODS: We report a case of a 35-year-old woman who presented with acute limb ischemia secondary to malignant obstruction of bilateral femoral arteries. She was found to have extensive intracranial, pulmonary, hepatic, splenic and cardiac metastasis two years after a first trimester spontaneous abortion. Her initial &bgr;-HCG was 1,228,233 IU/L. RESULTS: The patient was treated initially with whole brain radiation therapy (WBRT) for two weeks with concurrent weekly etoposide and cisplatin to address extensive metastatic disease in both the brain and liver. EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine) was withheld initially due to concern for bleeding with concurrent radiation therapy. Upon completion of WBRT, the patient completed eleven cycles of EMA-CO She also successfully underwent bilateral lower extremity embolectomies. CONCLUSION: After completion of multi-agent chemotherapy and whole brain radiation therapy, the patient had total resolution of radiographic findings of metastatic disease and normalization of &bgr;-HCG. This case highlights the variable presentation of GTN and reiterates excellent response to treatment despite massive tumor burden.

Perceived versus measured functional vaginal capacity in cancer patients with sexual function concerns.

170 Background: Actual and perceived loss of vaginal capacity can be a source of distress among female cancer survivors. The objective of this study was to assess perceived (PC) versus measured (MC) functional vaginal capacity in patients presenting with sexual function concerns. METHODS This was a cross-sectional registry-based study of women seen at the Program in Integrative Sexual Medicine for Women and Girls with Cancer (PRISM) Clinic. During the visit, patients were presented with graduated vaginal dilators and asked to select the largest dilator they perceived could be inserted without pain (PC) and the dilator representing their desired functional capacity (DC) (for patients with a male partner, this was the size closest to the partners erect penis). Two models of dilators were offered. Dilators were numbered 1-24 in order of increasing volume. If the patient could accommodate the dilator chosen as PC without pain, she was examined with dilators of gradually increasing size until the patient reported discomfort. The largest dilator tolerated without pain was MC. Differences between PC and MC, and between DC and MC were calculated. The association between penetrative sexual activity in the prior 4 weeks and accuracy of PC was assessed using the Mann-Whitney U test. RESULTS Mean patient age was 46 years (range 21-80, N=69). Most patients had breast (43%) or a gynecologic cancer (16%); 29% had benign disease. Nearly half reported two or more sexual concerns; painful intercourse (81%), vaginal complaints (21%), and loss of libido (19%) were most common. Median PC was 50cm3 (IQR 35-65cm3), median MC was 81cm3 (IQR 60-90cm3), and median DC was 90cm3 (IQR 81-132cm3). PC equaled MC in 22%. PC was less than MC in 75% and less than DC in 81% of patients. Of patients with PC less than DC, 41% had MC equal to or larger than DC. PC was closer to MC in patients reporting penetrative sexual activity in the prior 4 weeks (p=0.02). CONCLUSIONS In this single-site study, many cancer survivors seeking care for sexual concerns underestimate their functional vaginal capacity. Further study is needed to determine whether correcting patient perception of capacity lessens distress and improves function.